Algorithms for IV fluid therapy in adults
Algorithm 1: Assessment
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg; heart rate
>90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
Yes
No
Algorithm 2: Fluid Resuscitation
Initiate treatment

Identify cause of deficit and respond.

Give a fluid bolus of 500 ml of crystalloid
(containing sodium in the range of
130–154 mmol/l) over less than 15
minutes.
Assess the patient’s likely fluid and electrolyte needs

History: previous limited intake, thirst, abnormal losses, comorbidities.

Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension.

Clinical monitoring: NEWS, fluid balance charts, weight.

Laboratory assessments: FBC, urea, creatinine and electrolytes.
Yes
Can the patient meet their fluid and/or electrolyte needs orally or enterally?
Ensure nutrition and fluid needs are met
Also see Nutrition support in adults (NICE
clinical guideline 32).
No
Reassess the patient using the ABCDE
approach
Does the patient still need fluid
resuscitation? Seek expert help if unsure
Yes
Does the patient have complex fluid or
electrolyte replacement or abnormal
distribution issues?
Look for existing deficits or excesses, ongoing
abnormal losses, abnormal distribution or other
complex issues.
No
No
Does the patient have
signs of shock?
Yes
Yes
>2000 ml
given?
Yes
Algorithm 3: Routine Maintenance
Algorithm 4: Replacement and Redistribution
Existing fluid or
electrolyte deficits
or excesses
Check for:

dehydration

fluid overload

hyperkalaemia/
hypokalaemia
Estimate deficits or
excesses.
No
Seek expert help
Give maintenance IV fluids
Normal daily fluid and electrolyte requirements:



25–30 ml/kg/d water
1 mmol/kg/day sodium, potassium*, chloride
50–100 g/day glucose (e.g. glucose 5% contains
5 g/100ml).
No
Give a further fluid bolus of 250–500 ml of
crystalloid
Reassess and monitor the patient
Stop IV fluids when no longer needed.
Nasogastric fluids or enteral feeding are preferable
when maintenance needs are more than 3 days.
Ongoing abnormal fluid or
electrolyte losses
Redistribution and
other complex issues
Check ongoing losses and estimate
amounts. Check for:

vomiting and NG tube loss

biliary drainage loss

high/low volume ileal stoma
loss

diarrhoea/excess colostomy
loss

ongoing blood loss, e.g.
melaena

sweating/fever/dehydration

pancreatic/jejunal fistula/stoma
loss

urinary loss, e.g. post AKI
polyuria.
Check for:

gross oedema

severe sepsis

hypernatraemia/
hyponatraemia

renal, liver and/or
cardiac impairment.

post-operative fluid
retention and
redistribution

malnourished and
refeeding issues
Seek expert help if
necessary and estimate
requirements.
Prescribe by adding to or subtracting from routine maintenance, adjusting for all
other sources of fluid and electrolytes (oral, enteral and drug prescriptions)
Monitor and reassess fluid and biochemical status by clinical and laboratory
monitoring
*Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in a 24-hour period).
Potassium should not be added to intravenous fluid bags as this is dangerous.
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
© National Institute for Health and Care Excellence 2013. All rights reserved.
Algorithms for IV fluid therapy in adults
Algorithm 1: Assessment
Yes
Algorithm 2:
Fluid
Resuscitation
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach,
assess whether the patient is hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context.
Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg;
heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20
breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
No
Assess the patient’s likely fluid and electrolyte needs

History: previous limited intake, thirst, abnormal losses, comorbidities.

Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural
hypotension.

Clinical monitoring: NEWS, fluid balance charts, weight.

Laboratory assessments: FBC, urea, creatinine and electrolytes.
Can the patient meet their fluid and/or electrolyte needs orally or
enterally?
Yes
Ensure nutrition and fluid
needs are met
Also see Nutrition support in
adults (NICE clinical
guideline 32).
No
Does the patient have complex fluid or electrolyte replacement
or abnormal distribution issues?
Look for existing deficits or excesses, ongoing abnormal losses,
abnormal distribution or other complex issues.
Yes
Algorithm 4:
Replacement and
Redistribution
No
Algorithm 3: Routine
Maintenance
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
© National Institute for Health and Care Excellence 2013. All rights reserved.
© National Institute for Health and Care Excellence 2013. All rights reserved.
Algorithms for IV fluid therapy in adults
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is
hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid
resuscitation include: systolic BP <100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate
>20 breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
Yes
Algorithm 2: Fluid Resuscitation
Initiate treatment

Identify cause of deficit and respond.

Give a fluid bolus of 500 ml of crystalloid
(containing sodium in the range of
130–154 mmol/l) over less than15
minutes.
Reassess the patient using the ABCDE
approach
Does the patient still need fluid
resuscitation? Seek expert help if unsure
No
Yes
Does the patient have
signs of shock?
Yes
No
Assess the patient’s likely fluid
and electrolyte needs (Refer
algorithm 1 box 3)
Yes
>2000 ml given?
Seek expert help
No
Give a further fluid bolus of 250–500 ml of crystalloid
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
© National Institute for Health and Care Excellence 2013. All rights reserved.
Algorithms for IV fluid therapy in adults
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and
needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation
include: systolic BP <100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min;
NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
No
Yes
Algorithm 2: Fluid
Resuscitation
Assess the patient’s likely fluid and electrolyte needs

History: previous limited intake, thirst, abnormal losses, comorbidities.

Clinical examination: pulse, BP, capillary refill, JVP, oedema
(peripheral/pulmonary), postural hypotension.

Clinical monitoring: NEWS, fluid balance charts, weight.

Laboratory assessments: FBC, urea, creatinine and electrolytes.
No
Yes
Can the patient meet their fluid and/or electrolyte needs orally or enterally?
No
Does the patient have complex fluid or
electrolyte replacement or abnormal
distribution issues?
Yes
Look for existing deficits or excesses, ongoing
abnormal losses, abnormal distribution or other
complex issues.
Ensure nutrition
and fluid needs
are met
Also see Nutrition
support in adults
(NICE clinical
guideline 32).
Algorithm 4:
Replacement and
Redistribution
No
Algorithm 3: Routine Maintenance
Give maintenance IV fluids
Normal daily fluid and electrolyte requirements:



25–30 ml/kg/d water
1 mmol/kg/day sodium, potassium*, chloride
50–100 g/day glucose (e.g. glucose 5% contains
5 g/100ml).
Reassess and monitor the patient
Stop IV fluids when no longer needed.
Nasogastric fluids or enteral feeding are preferable
when maintenance needs are more than 3 days.
* Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids
containing 20 mmol and 40 mmol of potassium in a 24-hour period). Potassium should not be added to intravenous fluid bags as this is dangerous.
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
© National Institute for Health and Care Excellence 2013. All rights reserved.
Algorithms for IV fluid therapy in adults
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is
hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid
resuscitation include: systolic BP <100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch;
respiratory rate >20 breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
No
Assess the patient’s likely fluid and electrolyte needs

History: previous limited intake, thirst, abnormal losses, comorbidities.

Clinical examination: pulse, BP, capillary refill, JVP, oedema
(peripheral/pulmonary), postural hypotension.

Clinical monitoring: NEWS, fluid balance charts, weight.

Laboratory assessments: FBC, urea, creatinine and electrolytes.
No
Yes
Can the patient meet their fluid and/or electrolyte needs orally or enterally?
Ensure nutrition and fluid needs
are met
Also see Nutrition support in adults
(NICE clinical guideline 32).
No
Does the patient have complex fluid or electrolyte replacement or abnormal
distribution issues?
Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or
other complex issues.
Yes
Algorithm 4: Replacement and Redistribution
Existing fluid or
electrolyte deficits or
excesses
Check for:

dehydration

fluid overload

hyperkalaemia/
hypokalaemia
Estimate deficits or
excesses.
Ongoing abnormal fluid or
electrolyte losses
Check ongoing losses and
estimate amounts. Check for:

vomiting and NG tube loss

biliary drainage loss

high/low volume ileal
stoma loss

diarrhoea/excess
colostomy loss

ongoing blood loss, e.g.
melaena

sweating/fever/dehydration

pancreatic/jejunal
fistula/stoma loss

urinary loss, e.g. post AKI
polyuria.
Redistribution and other
complex issues
Check for:

gross oedema

severe sepsis

hypernatraemia/
hyponatraemia

renal, liver and/or cardiac
impairment.

post-operative fluid retention
and redistribution

malnourished and refeeding
issues
Seek expert help if necessary and
estimate requirements.
Prescribe by adding to or subtracting from routine maintenance, adjusting for all other
sources of fluid and electrolytes (oral, enteral and drug prescriptions)
Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
© National Institute for Health and Care Excellence 2013. All rights reserved.
.